ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: Acute pain related After 4 hours of INDEPENDENT

VITAL SIGNS to chemical injury nursing -Assess patient’s -To ensure that a
-BP- 120/80 agent intervention the pain including: patient receives
-PR- 72 patient will report location, effective pain
-RR-18 is relieved or onset/duration, relief, you must
-weakness controlled frequency, conduct a
-facial grimace quality, and thorough and
- restlessness intensity using a accurate pain
-body malaise pain scale of 0-10 assessment
-pain scale 8/10 every two hours.
-Monitor patient’s -Acute pain
vital signs for activates the
signs of pain sympathetic
including: branch of the ANS
increased heart causing such
rate, blood responses as
pressure, and increasing blood
respiratory rate pressure, and
every two hours. rapid heart and
respiratory
-Observe patient -Behavioral and
for nonverbal physiologic
indicators of pain responses are
including: facial indicators of pain
grimacing, in patients.
moaning,
guarding, and
crying during
assessment of
pain and vital
signs.
-Provide and -Non-
teach caregivers pharmacologic
non- measures support
pharmacologic analgesia therapy
comfort measures in reducing pain.
including
repositioning and
creating a low
stimulus
environment
when patient
reports pain prior
to discharge.
DEPENDENT -To maintain
-Administer acceptable level
analgesic as of pain and to
 indicated relieve pain

NCP# 2

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: Impaired skin After 8 hours of INDEPENDENT
-disruption of skin integrity related nursing
- to chemical injury intervention the
agent patient will
display
progressive
improvement of
wound or lesion
healing

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT
ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE
OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT

ASSESSMENT DIAGNOSES PLANNING INTERVENTION RATIONALE

OBJECTIVE: INDEPENDENT